concussion: updated guidelines for a new era of sports · 2020. 6. 30. · boston university...

Concussion:

Updated Guidelines for a New Era of

Sports

Douglas Comeau, DO, CAQSM, FAAFP

Medical Director, Sports Medicine

Director, Primary Care Sports Medicine Fellowship

Ryan Center for Sports Medicine at Boston University

Boston Medical Center

Head Team Physician, Boston University

Team Physician, Boston College

Boston University Slideshow Title Goes Here

Disclosures

• I, Douglas Comeau, nor any family members, have

any relevant financial relationships to be discussed,

directly or indirectly, referred to or illustrated with or

without recognition within the presentation


Learning Objectives

Identify the warning signs of concussion

Know appropriate return to play progression

Attempts at prevention

Future research


Concussion can happen at any moment


With the Game on the Line


And it can be on the road


Would you be ready as Team Physician?


The After Effects can change your outlook

on life…


Statistics

>300,000 mild traumatic brain injuries occur annually

Can happen in any sport

Much higher risk in game situation than in practice


History of concussion

40 years ago concussion first defined by Committee on Head Injury Nomenclature of the Congress of Neurological Surgeons

“immediate and transient impairment of neural functions, such as an alteration of consciousness, disturbance of vision and equilibrium due to brain stem involvement”

Over the next thirty years, over sixteen theories and return-to-play guidelines were published


Prior Grading Scales

Grade 1 Grade 2 Grade 3

Cantu No LOC

PTA < 30 “ LOC < 5 “

PTA 30” to

24’

LOC > 5 “

PTA > 24 ‘

Colorado Medical

Society

Transient

confusion

No PTA, no LOC

Transient

confusion

+ PTA , no LOC

LOC

American

Academy of

Neurologists

Transient

confusion

No LOC, sx < 15”

Transient

confusion

No LOC, sx > 15”

LOC


Prior Grading Scale Return

Grade 1 Grade 2 Grade 3

Cantu No sx for 1

week

No sx for 2

weeks

Out 1 mos,

No sx for 1

week

Colorado

Medical

Society

Sx < 20” Same day

No sx for 1

week

Out 1 mos, no

sx for 2 weeks

American

Academy of

Neurologist

Sx < 15” Same day

No sx for 1

week

Brief LOC: 1 week

Long LOC: 2 week


Why didn’t it work

Too many opinions

Too many controversies

Need for standard of care


Concussion Grading Scales

Abandoned with 2001 Vienna Conference

Now combined measures of recovery Injury severity

Injury prognosis

Individual-specific return to play

Severity graded once all symptoms resolved and athlete has returned to baseline

Number of concussion signs does not correlate with severity of concussion


Vienna Conference: 2001

First international symposium on

concussion

Redefined “sports” concussion

traumatically induced transient

disturbance of brain function caused

by a complex pathophysiologic

process.

subset of mild traumatic brain injury

which is generally self-limited and at

the less severe end of the brain

injury spectrum.


Defining the Nature of Concussion

Direct blow to the head, face, neck with an “impulsive” force

transmitted to the head

Rapid onset of short-lived impairment of neurological

function that resolves spontaneously

Neuro-pathologic changes

Acute symptoms are functional instead of structural

Graded set of clinical syndromes

May or may not involve loss of consciousness

Resolution typically follows sequelae

Typically associated with grossly normal structural

neuroimaging studies


Second International Conference on

Concussion: Prague 2005

Second International Conference on Concussion and

Sport

IHF, FIFA, IOC

Need to update grading system and management

Definition unchanged

Nature of Concussion unchanged except for the

following

Post-concussive symptoms may be prolonged or persistent


Prague Concussion Classification

New classification

system recommended

with Prague Conference

Simple versus complex

Complex


Prague “Simple” Concussion: Defined

Most common form of concussion

Injury that progressively resolves without complication in 7-10 days

Limit play and training while symptomatic

No further intervention typically required

Athlete resumes sport without problem

Mental status screen at time of the injury

No formal neuropsychological testing typically required


Prague “Simple” Concussion: Treatment

Rest until symptoms resolve Minimum 24 hours

Graded program of exertion before return to sport Bike

Running

Field

Helmet without pads

Return

Typically seven days


Prague “Complex” Concussion: Defined

Athlete suffers persistent symptoms Including recurrence with

exertion

Specific sequelae Concussive convulsions

Prolonged LOC Greater than 1 minute

Prolonged cognitive impairment after injury

Multiple concussions over time

Repeated concussions with progressively less impact

Further neuropsychological testing required prior to return to play in a multi-disciplinary team approach


3rd International Conference on Concussion:

Zurich 2008

Simple vs. Complex does not work for all

Treat each concussion individually

Neuropsychiatric testing for all concussions could be

ideal

Developed SCAT2

New Research on Exercise Testing for PCS


Concussion

Zurich 2012: 4th international conference on concussion in sport

Held in November 2012

Multi-specialty meeting

PCSM, Neurosurgery, Neurology, Family Medicine, Pediatrics,

Orthopedic Surgery all represented

Multiple professional organizations worldwide

Evaluate concussion diagnosis, management, and make any

necessary changes

Developed SCAT3, including a child SCAT3

Neuropsychologist recommended but not mandated

Vestibular rehab for chronic symptoms

Added exercise from chronic symptoms


Pathophysiological Basis of Concussion

No animal or experimental model to date for sports

concussion

Trauma to neurons leads to temporary ionic

disequilibrium

This leads to an “energy crisis” for the brain

Some experimental studies in TBI show Biochemical Change

Metabolic Change

Gene Expression Change


Pathophysiology, subtypes

Clinical Manifestations Confusion, Memory Problems, LOC

Anatomic Localization Cerebral versus brainstem

Biomechanical Impact Rotational versus linear force

Genetic Phenotype Apo-lipoprotein epsilon 4 (ApoE4) positive

Neuropathological change Structural injury versus none


Pathophysiology

Post-concussive vulnerability, second blow before the brain has recovered results in worsening

metabolic changes within the cell.

Concussed brain is less responsive to usual neural

activation Premature cognitive or physical activity before full recovery has

occurred

Increased vulnerability to prolonged dysfunction


Risk Factors

Concussion

Good Evidence

Previous history

Fair Evidence

Sport

Position

Playing Style

Gender

Weak Evidence

Migraines

Genetics

Prolonged Recovery

Good Evidence

Young age

Greater number, severity,

duration of symptoms

Fair Evidence

Pre-injury learning

disabilities, mood

disorders, ADD

Migraine


Questions on History and Pathology?

Boston University Sports Medicine


Pre-participatory Exam

Number of concussions

Symptoms of each concussion

Suspect undocumented concussion in history of cervical and facial injuries

Teammates and coaches unreliable

Inquire about protective equipment at time of injury

Baseline cognitive assessment (SCAT3) done prior to the season

If resources available, cognitive evaluation regardless of age or level.


Concussion Defined

From Sport Concussion Assessment Tool 3rd Edition

Disturbance in brain function caused by a direct or

indirect force to the head. It results in a variety of non-

specific signs and/or symptoms and most often does

not involve loss of consciousness. Concussion should

be expected in any one or more of the following:

Symptoms (eg. Headache)

Physical signs (eg. unsteadiness)

Impaired brain function (eg. Confusion)

Abnormal behavior (eg. change in personality)


Indications for Emergency Management

Glascow Coma Scale < 15

Deteriorating mental status

Potential spinal injury

Progressive, worsening symptoms or new neurologic

signs


Sideline Assessment

• The unconscious athlete

• ABCs

• Cervical spine

• Immediate referral?


Sideline Assessment

• History

• Mechanism of Injury

• Assess level of alertness, speech

• Amnesia

• Graded Symptom Evaluation


Graded Symptom Evaluation

Athlete scores themselves at the time of evaluation as how they

currently feel (initial evaluation only)

Scoring 06

None

Mild

Moderate

Severe

For follow-up visits, same scoring system over a period of time

Never

Sometimes

Always



Headache

“pressure in head”

neck pain

nausea or vomiting

Dizziness

Blurred vision

Balance problems

Sensitivity to light

Sensitivity to noise

Feeling slowed down

Feeling like “in a fog“

“Don’t feel right”

Difficulty concentrating

Difficulty remembering

Fatigue or low energy

Confusion

Drowsiness

trouble falling asleep

more emotional

irritability

Sadness

nervous or Anxious



Total number of symptoms (Maximum possible 22)

Symptom severity score (Maximum possible 132)

Do the symptoms get worse with physical activity?

Do the symptoms get worse with mental activity?

With or without parent input (in office)

if you know the athlete well prior to the injury, how

different is the athlete acting compared to his / her

usual self?


Sideline Assessment

• Physical Exam

• Vital signs

• Cervical spine

• Neurological exam


Assessment Tools

• Standardized Assessment of Concussion (SAC)

• Balance Error Scoring System (BESS)

• Sport Concussion Assessment Tool 3 (SCAT3) • Available online for free

• Smartphone app for free


BESS: Live Examples

BESS Double Leg

BESS Single Leg

BESS Single Leg

Tandem Gait

http://www.youtube.com/watch?v=N50BpANuNQc

http://www.youtube.com/watch?v=HrBdMiVPdNA

http://www.youtube.com/watch?v=1QWh71y3hjc

http://www.youtube.com/watch?v=N50BpANuNQc


Biodex Balance Machine


Biodex Report Comparison


Return to Play Decision

• If a concussion is diagnosed

the athlete should not return to

play during that day

• Still unsure? Functional testing


Sideline 101

There is NO same day return to

play for athletes diagnosed with

concussion


Monitoring and Instructions

• Frequent assessments for changes in status

• Instructions for athletes/parents


Symptomatic Treatment

Early symptoms are generally best manage by cognitive and

physical rest

OTC analgesics are commonly used for headache symptoms

Other commonly used medications/supplements have an unclear

role in symptom management

ADHD medications

Migraine Medication

Fish Oil

Others

Care should be taken not to cloud the return to play decision by

masking post-concussive symptoms


Physical and Cognitive Rest


Second Impact Syndrome

A second concussion prior to the first symptoms dissipating

Physical paralysis

Seizures

Mental Disabilities

Death in 50% of athletes F.H.: 9/98 California, HS MLB, brain hemorrhage

A.B.: 9/98 Kansas City, HS FB, Subdural hematoma

D.B.: 2/97, San Antonio, 19 YO boxer, concussion


Return to Play

Rest until asymptomatic (physical and mental)

Light aerobic exercise (stationary cycle)

Sport-specific training

Non-contact training drills (start light resistance

training)

Full contact training after medical clearance

Return to competition (game play)

No less than 24 hours before each stage


Neuropsychological testing

Pre-injury/Post-injury comparison

Old school pencil to paper modality

New school computerized testing

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

Concussion Resolution Index

CogSport

Well established, mixed support

Data does not support one test over the other; however, research is ongoing

ImPACT frequently used at high school, colleges, professional levels


ImPACT Example


Neuropsychological Testing

Concussions can be managed

appropriately without the use of

neuropsychological testing

In some cases, properly

administered and interpreted NP

testing may provide added value to

assess cognitive function and

recovery in the management of

sports concussions.


Neuropsychological Testing

Computerized neuropsychological testing should be

interpreted by healthcare professionals trained and familiar

with the type of test and the individual test limitations

Neuropsychological testing should be used only as part of a

comprehensive concussion management strategy and should

not be used in isolation

It is unknown if use of neuropsychological testing in the

management of sports concussion helps prevent recurrent

concussion, catastrophic injury, or long-term complications.


Neuroimaging Testing

Imaging is used to rule out structural brain or cranial injury

Generally in the acute or sub-acute setting

Newer imaging techniques are being studied but clinical

significance is not clear

functional MRI

Diffusion tensor imaging

Magnetic Resonance Spectroscopy


Functional MRI


Newer Techniques for Return

Vestibular Rehab

Speech and language Pathology

? Need for standardized cognitive return


Pediatric Concussion

Developing musculoskeletal system influences musculoskeletal dynamics

Biomechanical Structures still growing

Pathophysiologic Higher incidence of brain

swelling, cerebral edema

Neurophysiologic Immature brain more

vulnerable to injury

Contextual Rapid processing of

information


Pedi Concussive Management

Similar to adult concussion

No standardized return to school

Section 504: non-discrimination of students with disabilities

Individualized education programs

Informal accommodations

Neuropsychological testing to all those with long-standing post-concussive s/sx


Child Maddock’s Score (new SCAT3)

Perform for children between 5-12 YO

Where are we at now?

is it before or after lunch?

What did you have last lesson / class?

What is your teacher‘s name?


Child Graded Symptom Evaluation

I have trouble paying attention

I get distracted easily

I have a hard time concentrating

I have problems remembering what people tell me

I have problems following directions

I daydream too much

I get confused

I forget things

I have problems finishing things

I have trouble figuring things out

it’s hard for me to learn new things

I have headaches

I feel dizzy

I feel like the room is spinning

I feel like I am going to faint

things are blurry when i look at them

I see double

I feel sick to my stomach

I get tired a lot

I get tired easily


Parent Graded Symptom Checklist

has trouble sustaining attention

is easily distracted

has difficulty concentrating

has problems remembering what

he/she is told

has difficulty following directions

tends to daydream

gets confused

is forgetful

has difficulty completing tasks

has poor problem solving skills

has problems learning

has headaches

feels dizzy

has a feeling that the room is

spinning

feels faint

has blurred vision

has double vision

experiences nausea

gets tired a lot

gets tired easily


Pediatric Concussion Grading scale

Total symptoms: 20

Total symptom score: 60

Score System: 03


Post-Concussive Syndrome

No universal definition of post-concussive syndrome

Persistent symptoms and signs of concussion for weeks

to months after the incident

Symptoms of post-concussion syndrome can be

subjective or objective and are often vague and non-

specific making the diagnosis difficult.


Post-Concussion Syndrome

Risk factors not clear

No correlation between severity of injury on

presentation and development of post concussive

syndrome

Rehabilitation

Cognitive therapy may be useful in some circumstances

Progressive exercise programs may improve recovery times

Graded exercise testing to determine symptoms threshold

Vestibular rehabilitation


Insomnia and Depression in PCS

Effective

Nortriptyline

Amitriptyline

Trazodone

Mixed

Gabapentin

SSRIs

Ineffective

Ambien


Long-Term Effects

Research suggests that recurrent concussion may be associated

with depression and progressive neurodegenerative conditions such

as mild cognitive impairment and Alzheimer’s disease.

Small case series have led to the hypothesis that repetitive brain

trauma is associated with a progressive neurodegenerative disease

known as chronic traumatic encephalopathy(CTE).

However, no prospective longitudinal studies are available, and

more research is needed to understand any link between recurrent

concussion or sub-concussive impacts and this neurodegenerative

condition


Center for the Study of Traumatic

Encephalopathy (CSTE)

Founded in 2008

Joint venture between BU School of Medicine and

Sports Legacy Institute

Studied over 100 brains post-mortem

Deposit of tau protein

18 of 19 NFL players with CTE

In coordination with NFL


Prevention

Rule Changes Spearing

No head checking in hockey

Delay contact

Protective equipment has not been shown to decrease

the risk or severity of concussions

Risk compensation of equipment change


Recent Rule Changes

Pop Warner Contact

NFL Practices

Penalties

NCAA Division 1, 1A football Practice

MLB 7 day DL


Medicolegal Considerations

Concussion

Management uses

clinical judgment on

an individual basis

Science of

concussion at an

early stage

State Legislation

Riddell Lawsuit


Education

Coaches, parents, players, physicians, ATC

Classroom instruction

Video

Combined effort

International effort


Take Home Points

• Very few concussions present with loss of

consciousness – Be vigilant!

• Follow a standard assessment algorithm including

history, physical, special testing

• No same day return to play


Future

Research ongoing, with difficulty in obtaining

double-blinded prospective studies

Validate current assessment tools

Delineate role of neuropsychological testing

Improve identification of those at-risk of PCS,

prolonged symptoms

Enhanced imaging, biomarkers

Minimum time out for concussion?


References • Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic Review of the Balance

Error Scoring System. Sports Health. 2011 April;3(3):287-295.

• Eckner JT, Kutcher JS. Concussion symptom scales and sideline assessment

tools: a critical literature update. Curr Sports Med Rep. 2010 Jan-Feb;9(1):8-15.

• Guskiewicz KM. Balance assessment in the management of sport-related

concussion. Clin Sports Med. 2011 Jan;30(1):89-102, ix.

• Guskiewicz KM, Bruce SL, Cantu RC et al. Research Based Recommendations

on Management of Sports Related Concussions: Summary of the National Athletic

Trainers Position Statement. Br J Sports Med 2006;40:6-10.

• McCrea M. Standardized Mental Status Testing on the Sideline After Sport-

Related Concussion. J Athl Train. 2001 Sep;36(3):274-279.

• McCroy, P., et al. Consensus statement on concussion in sport: the 4th

International Conference on Concussion in Sport held in Zurich, November 2012.

Br J Sports Med 2013;47:250-258

• Valovich McLeod TC, Bay RC, Heil J, McVeigh SD. Identification of Sport and

Recreational Activity Concussion History Through the Pre-Participation Screening

and a Symptom Survey in Young Athletes. Clinical Journal of Sport Medicine.

2008;18(3):235-240.


Ryan Center for Sports Medicine

915 Commonwealth Ave, Rear

Boston, MA 02215 (Behind BU Fit-Rec)

617-358-3400

[email protected]

Team Physicians for:

BU, BC, Emerson, Boston Public Schools, USA Gymnastics

First Primary Care Sports Medicine Center in Boston

Multi-Disciplinary Sports Medicine Center

mailto:[email protected]


What does the Ryan Center Offer?

Concussion Clinic

Trained sports medicine

physicians

Biodex Balance Machine

ImPACT

neuropsychological testing

Vestibular rehab

OMT

MSK Ultrasound

Physical Therapy

X-Ray

Treadmill Testing

Fracture Care

PRP


Thank You!

concussion: updated guidelines for a new era of sports · 2020. 6. 30. · boston university...

Documents